Interest Form for Health and Reentry Project Operational Assistance

Fill out the interest form below and select "done" when complete.

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1. Agency name (Required.)

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2. Entity type (Required.)

Prison

Jail

Other (please specify)

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3. First Name (Required.)

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4. Last Name (Required.)

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5. Position/Title (Required.)

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6. Email (Required.)

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7. Phone

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8. State (Required.)

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9. County, if representing a jail

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10. Average daily population

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11. Of the following options below, please select the topics in which you are most interested in making operational improvements. You can select more than one. (Required.)

a. Partnering with State Medicaid Agency

b. Partnering with Managed Care Organizations/Community Based Providers

c. Youth and Young Adult Requirements

d. Data and Information Sharing

e. Benefit Enrollment/Re-enrollment

f. Medicaid Reentry Demonstration Waivers

g. Continuity of Care

h. Continuing Access to Prescription Medications

Other (please specify)

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12. How would you prefer this information be communicated? You can select more than one. (Required.)

a. Training;

b. Virtual Assessment of health-related capacity;

c. Virtual or on-site consultations to support operational planning;

d. Peer-to-peer learning; or

e. Customized resources.

Other (please specify)

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13. Effective technical assistance requires dedicated staffing resources. Please indicate below the number of hours per month you or someone else in your agency can commit to the engagement. (Required.)

a. Lighter touch, roughly 2 hours per month

b. Moderate support, roughly 4 hours per month

c. Intensive, as much as 6-8 hours per month

Interest Form for Health and Reentry Project Operational Assistance

Question Title

* 1. Agency name (Required.)

Question Title

* 2. Entity type (Required.)

Question Title

* 3. First Name (Required.)

Question Title

* 4. Last Name (Required.)

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* 5. Position/Title (Required.)

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* 6. Email (Required.)

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* 7. Phone

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* 8. State (Required.)

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* 9. County, if representing a jail

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* 10. Average daily population

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* 11. Of the following options below, please select the topics in which you are most interested in making operational improvements. You can select more than one. (Required.)

Question Title

* 12. How would you prefer this information be communicated? You can select more than one. (Required.)

Question Title

* 13. Effective technical assistance requires dedicated staffing resources. Please indicate below the number of hours per month you or someone else in your agency can commit to the engagement. (Required.)

1. Agency name (Required.)

2. Entity type (Required.)

3. First Name (Required.)

4. Last Name (Required.)

5. Position/Title (Required.)

6. Email (Required.)

7. Phone

8. State (Required.)

9. County, if representing a jail

10. Average daily population

11. Of the following options below, please select the topics in which you are most interested in making operational improvements. You can select more than one. (Required.)

12. How would you prefer this information be communicated? You can select more than one. (Required.)

13. Effective technical assistance requires dedicated staffing resources. Please indicate below the number of hours per month you or someone else in your agency can commit to the engagement. (Required.)